Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sherbrooke Village during CMS and state inspections, most recent first.
Two residents did not receive adequate pain management in line with facility policy. One resident was admitted with a pelvic fracture and hospital discharge orders for multiple pain medications, yet no pharmacologic or non‑pharmacologic pain interventions were administered for many hours after admission, despite documented escalating pain up to 10/10 and descriptions of excruciating pain overnight. Medication orders for acetaminophen, hydromorphone, cyclobenzaprine, and gabapentin were present, but the MAR showed they were not given as ordered, and staff interviews revealed confusion about eKit use, lack of signed narcotic scripts, and failure to secure timely pain control. Another resident with a coccyx pressure ulcer reported significant pain during transfers and wound care, frequently yelling and moaning, while the care plan did not address wound‑related pain and PRN acetaminophen was never administered over multiple opportunities, with hydrocodone‑acetaminophen given inconsistently. CNAs and a CMT reported relaying pain complaints to nursing, but were unsure if pain medications were provided, and wound care had to be stopped due to uncontrolled pain.
Staff failed to consistently treat residents with dignity and to follow the facility’s cell phone policy. A cognitively intact resident with Parkinson’s disease, dementia, and COPD was denied requested assistance to the dining room and was told by a CNA to move using his/her feet despite visible discomfort, until another aide intervened. A resident with severe cognitive impairment and significant neurologic deficits was fed by a CNA who wore earbuds and looked at a cell phone during the meal. Other cognitively intact residents reported that staff frequently used cell phones and headphones in hallways and while providing care, and resident council members described staff turning off call lights while stating they were not the assigned aide, leaving without notifying others, and talking loudly or yelling on the halls at night. Observations and staff interviews confirmed that these actions conflicted with the facility’s stated expectations that residents be treated with respect and that personal cell phones and headphones not be used in resident care areas.
Surveyors found that hot foods were not maintained at the facility’s required temperature standard during observed meal services, with items such as soup, meatballs, cream of wheat, scrambled eggs, and biscuits and gravy all measuring below 135°F. Multiple cognitively intact residents, including individuals with COPD, dementia, quadriplegia, chronic kidney disease, heart failure, diabetes, depression, and anxiety, reported that their meals—especially room trays—were usually or always served cold. These findings conflicted with the stated expectations of the dietary supervisor, administrator, and DON that food be delivered at safe and palatable temperatures.
A cognitively intact resident with Parkinson’s disease, dementia, COPD, and frequent bowel and bladder incontinence, who depended on staff for toileting hygiene, was left soiled and wet for an extended period despite calling out for help. The resident’s call light was wrapped around the bed frame and out of reach, and over more than two hours the resident remained in bed with a strong odor of stool and urine, repeatedly stating they were soiled and had not been checked. When a CNA and an LPN finally entered, they found the brief and bed pad saturated with urine and a large amount of diarrhea, contrary to the care plan and staff statements that incontinent residents should be checked every one to two hours and kept clean, dry, and odor free.
A resident with cognitive impairment, incontinence, and neurogenic bladder used a family-applied condom catheter at night for over a month without any physician orders, care plan interventions, or documented monitoring. Surveyors observed the drainage bag and tubing on the floor, with the condom catheter secured by duct tape. A CNA reported the family applied and removed the device and managed the drainage bag, while nursing staff, including LPNs and the DON, stated they were unaware of the device’s use and that no documentation, skin assessments, or monitoring of urinary output and characteristics had been completed.
Surveyors identified that the facility’s medication error rate exceeded 5%, based on three errors in 27 observed opportunities. A resident with dementia and hypotension received Midodrine without a BP check beforehand, and the CMT administering it did not know the drug’s purpose. Another resident with severe cognitive impairment and multiple comorbidities had two glaucoma eye drop medications ordered, but the care plan did not address the need for eye drops, and the CMT administered both ophthalmic solutions back-to-back without the required pause or proper technique, contrary to facility policy and manufacturer instructions.
A resident with vascular dementia, COPD, and CKD experienced inadequate foot care, resulting in dry skin and a blister on the left foot. Despite physician orders for skin assessments and wound care, there were no orders for lotion or preventive ointments, and the care plan was not updated. Observations showed dry, flaky skin and a raw area on the left foot. Staff were aware of the issues but failed to document or treat the dry skin, and the facility's skin integrity policy was not followed.
A resident with a history of dementia and confusion was found with serious injuries, including a bloodied face, in a LTC facility. Despite the severity and unknown origin of the injuries, the facility failed to report the incident to DHSS within the required two-hour timeframe, assuming it was an unwitnessed fall.
The facility failed to maintain a licensed Administrator, leading to a gap in compliance with regulations. The DBO temporarily filled the role without a license after Administrator A's license expired, and efforts to contract a new Administrator were unsuccessful.
The facility failed to conduct NA registry checks for three out of ten sampled new hires, as required by their abuse prevention policy. Interviews revealed a lack of awareness about the necessity of these checks for non-nursing staff, potentially compromising resident safety.
The facility failed to provide bedtime snacks, offering them only mid-day between lunch and dinner. Residents reported not receiving snacks after dinner, with one experiencing low blood sugar at night. Snacks were stored in cabinets known only to staff, and there was uncertainty about their availability. The DON stated snacks should be available after dinner, but this was not ensured.
The facility failed to follow infection control practices, including not cleaning treatment carts between rooms and neglecting hand hygiene during wound care. Staff did not wear appropriate PPE during high-contact activities with residents on enhanced barrier precautions. These deficiencies were observed despite the facility's policies and expectations for infection control.
A resident with a surgical wound and low blood pressure experienced purulent drainage and elevated temperature, but the facility failed to notify the physician promptly. Despite documentation of the resident's condition, there was a lack of communication between shifts, leading to a delay in medical intervention. Interviews revealed inconsistencies in reporting practices, and the Director of Nursing expected immediate notification of the physician, which did not occur.
A facility failed to clarify medication orders, leading to duplicated doses for a resident with Alzheimer's and GERD. Additionally, another resident with a dehisced surgical incision was not sent to the hospital in a timely manner despite physician orders. Communication lapses and task delegation issues contributed to these deficiencies.
A facility failed to implement a stop date for a PRN psychotropic medication prescribed to a resident with impaired cognition and behaviors. The resident was given Lorazepam without a specified end date, contrary to the facility's policy requiring a 14-day stop date for PRN antianxiety medications. Interviews with the DON and administrator confirmed the oversight, revealing a deficiency in medication management practices.
The facility failed to properly label and store medications, as observed in a survey. An expired Pantoprazole suspension and an undated PPD vial were found in medication room refrigerators. Additionally, temperature logs for medication refrigerators were incomplete, with several missing entries and out-of-range temperatures. Staff interviews revealed lapses in responsibility for checking expired medications and logging temperatures.
The facility did not make the most recent survey and complaint investigation results accessible to residents and visitors. Observations showed no survey results at the entrance, lobby, or receptionist desk, and no signs indicating their location. Residents and staff were unaware of the binder's whereabouts, with suggestions it might be in storage due to lobby construction.
Failure to Provide Timely and Adequate Pain Management for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate pain management for two residents in accordance with its own pain management policy. For one resident with a recent pelvic fracture and history of intractable pain, the facility did not administer any pharmacologic or non‑pharmacologic pain interventions for approximately 20 hours after admission from the hospital, despite hospital discharge instructions that included multiple pain medications. The hospital’s After Visit Summary listed scheduled and PRN orders for acetaminophen, cyclobenzaprine, hydromorphone, and gabapentin, with the last doses given shortly before discharge. On admission, the RN documented the resident as alert and oriented with multiple fractures and chronic pain conditions, and noted that medications were verified with the in‑house NP, but only non‑pain‑related changes were made at that time. The electronic physician orders later reflected orders for Tylenol, hydromorphone, cyclobenzaprine, and gabapentin, yet the MAR showed that none of these pain medications were administered on the day of admission or the following day, except for a single gabapentin dose. Overnight, the resident’s pain escalated significantly. A skilled evaluation note documented a pain score of 4/10 with a notation that PRN medication was provided, but the MAR did not show any corresponding administration of ordered pain medications. Subsequent pain level summaries recorded the resident’s pain as 4/10 and then 10/10, and a nurse’s progress note described the resident as in excruciating pain, awake crying most of the night, and frequently using the call light for repositioning. The nurse contacted the on‑call provider about the increased pain and later documented that the NP recommended sending the resident back to the hospital for pain management. Interviews revealed that the admitting RN did not recall the resident complaining of pain and stated that narcotics could not be pulled from the eKit without signed scripts, and that residents needed to understand the facility would not have their pain medications immediately. The night RN stated that if Tylenol had been ordered it would have been given, but could not confirm administration and acknowledged that documentation should have reflected any Tylenol use. The pharmacy vendor reported having no record of the resident, and the DON stated she expected staff to verify medications, obtain signed scripts, and use available alternatives and non‑pharmacologic interventions, which were not documented as occurring. The second resident had a coccyx pressure ulcer and reported pain associated with this wound, but the facility did not consistently implement pain control interventions during wound care. The resident’s MDS showed occasional pain and multiple comorbidities, and physician orders included PRN hydrocodone‑acetaminophen and acetaminophen, along with a pain scale each shift. The care plan addressed risk for pressure ulcer development and skin integrity but did not address pain related to the existing coccyx pressure ulcer. MAR review showed that PRN acetaminophen was not administered for any of 14 possible opportunities, and hydrocodone‑acetaminophen was given only 8 of 12 possible times, including a dose earlier on the day of observation. During wound care and transfers, the resident repeatedly stated that it hurt and described multiple sore spots, yelling and moaning while being turned and while the wound was cleansed. Staff acknowledged that the resident complained of pain frequently and that they reported this to the nurse, but they were unsure whether pain medication was administered. Wound care had to be stopped due to the resident’s pain, and the Wound Nurse stated she would contact the provider for new pain management orders. The DON later stated she expected staff to address residents’ pain comments and administer medications as ordered, which did not occur consistently for this resident during wound treatment.
Failure to Maintain Resident Dignity and Enforce Cell Phone Restrictions
Penalty
Summary
The deficiency involves failure to honor residents’ rights to dignity and appropriate assistance, and failure to enforce the facility’s prohibition on staff use of personal cell phones in resident care areas. One cognitively intact resident with Parkinson’s disease, dementia, and COPD was observed in a wheelchair at the end of a hallway asking a CNA for help to get to the dining room. The CNA refused to push the resident because the wheelchair had no foot pedals, instructed the resident to move using his/her feet, and repeated this direction even as the resident only advanced a few feet and appeared uncomfortable. Another aide ultimately assisted the resident into the dining room. In later interviews, a CNA, an LPN, and facility leadership all stated that staff should assist residents when they ask for help and that residents should be treated and spoken to in a dignified manner. The report also documents multiple instances of staff using personal cell phones and headphones in resident care areas and during direct care, contrary to the facility’s written policy. A resident with severe cognitive impairment and multiple neurologic deficits was being fed in the dining room by a CNA who had earbuds in and was looking at a cell phone while checking a text message. Other cognitively intact residents reported that staff were on their phones frequently, including in hallways and while providing care, and that staff used phones and headphones during care encounters. Observations confirmed that one CNA sat texting on a cell phone in a hallway lounge with multiple residents present, and another CNA sat next to a resident on a couch wearing headphones and looking at a phone, and was later seen in the hallway wearing headphones and looking at the phone. During a resident council meeting, several residents reported prior concerns to administration about staff not treating residents in a dignified manner. They stated that care staff often entered rooms, turned off call lights while saying "I’m not your aide," and left without notifying another staff member that the resident needed care. Residents also reported that staff were often heard laughing, talking loudly, or yelling to one another on the halls during the night shift, and had been observed on their cell phones while providing care. Staff interviews, including with a CNA, an LPN, the Administrator, and the DON, confirmed that the facility’s expectation was that personal cell phones and headphones not be used in resident care areas and that cell phone use should be limited to the break room, underscoring that the observed and reported behaviors were inconsistent with facility policy and resident rights.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure food and beverages were served at safe and appetizing temperatures, as evidenced by multiple temperature measurements and resident interviews. The facility’s undated meal service temperature log required hot foods to be maintained at or above 135°F in the steam table and cold foods at or below 41°F. However, during a lunch observation on 4/8/26 in the memory care unit, soup measured 126.8°F and meatballs measured 129.3°F, both below the required hot-holding temperature. During a breakfast tray observation on 4/9/26 on the 300 hall, cream of wheat measured 80°F, scrambled eggs 109°F, and biscuits and gravy 111.1°F, all below the facility’s stated hot food standard. Interviews with cognitively intact residents further showed a pattern of food being served cold. One resident with COPD, muscle weakness, depression, and anxiety reported that food was always served cold. Another resident with dementia, muscle weakness, and quadriplegia stated that food was normally served cold when eaten in the room. A resident with muscle weakness, seizures, chronic kidney disease, and heart failure reported food was served cold most days. A resident with heart failure, diabetes, chronic kidney disease, and depression said room trays were normally served cold, and another resident with depression, anxiety, and high blood pressure stated the food was always served cold. The Dietary Supervisor, Administrator, and DON each stated they expected food to be served at safe and palatable temperatures, which was inconsistent with the observed temperatures and resident reports.
Failure to Provide Timely Incontinence and Perineal Care
Penalty
Summary
The facility failed to provide timely and appropriate ADL care, specifically perineal care and toileting assistance, to a cognitively intact resident who was frequently incontinent of bowel and bladder and dependent on staff for toileting hygiene. The resident’s care plan directed staff to assist with bathroom use as desired, offer toileting before and after meals and at bedtime, and clean the perineum after each incontinent episode. On the survey day, the resident was heard yelling for a nurse from the hallway, reporting they had been calling for help for about 30 minutes because they needed to use the bathroom. The resident’s call light was wrapped around the bed frame and out of reach, preventing the resident from calling for assistance. Over the course of more than two hours of observation, the resident remained in bed with a strong odor of stool and later of both stool and urine, repeatedly stating they were soiled, wet, and had not been checked on. Staff did not enter the room to provide care until approximately 11:04 A.M., at which time a CNA and an LPN found the resident’s brief and bed pad saturated with urine and a large amount of diarrhea present. The resident stated they had not been changed all night or that morning. Facility staff, including an LPN, a CNA, and the DON, reported that incontinent residents were expected to be checked every one to two hours and to be kept clean, dry, and odor free, indicating that the observed delay of over two hours in responding to the resident’s needs and the condition in which the resident was found did not meet the facility’s stated expectations or policy for perineal care and incontinence management.
Lack of Orders and Monitoring for Family-Applied External Urinary Device
Penalty
Summary
The facility failed to ensure a resident using an external urinary collection device had appropriate physician orders, care instructions, and monitoring. The resident had moderate cognitive impairment, was always incontinent of bowel and bladder, and had diagnoses including stroke and neurogenic bladder. The resident’s MDS did not indicate use of an external or indwelling catheter, and the care plan only addressed bowel and bladder incontinence with interventions such as assisting to the bathroom and cleansing the peri-area after incontinence episodes. There was no care plan focus or interventions related to an external urinary drainage device, and the physician order sheet contained no orders for such a device. Surveyors observed a urinary drainage bag filled with yellow urine in a basin on the floor, with catheter tubing on the floor and a condom catheter attached and secured with grey duct tape. A CNA reported that the resident’s family member had been applying the condom catheter and duct tape every evening for over a month, and that the CNA removed it each morning, but did not empty the drainage bag, leaving that to the family member. Multiple LPNs, including those responsible for the resident’s care, stated they were unaware the resident was using a condom catheter at night and that a family member was securing it with duct tape. The DON also reported being unaware of the device’s use and expected that staff would have notified nursing so that documentation, skin checks, physician orders, monitoring, and family education related to the external urinary drainage device would occur, none of which had been done.
Medication Error Rate Above 5% Due to Improper Midodrine and Ophthalmic Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying an 11.11% error rate based on 3 errors out of 27 medication administration opportunities observed. One deficiency involved a resident with dementia, hearing loss, and hypotension whose care plan included hypotension management with medications as ordered and monitoring for side effects and effectiveness. The resident had an order for Midodrine 10 mg PO three times daily, but there was no corresponding order to check blood pressure prior to administration. During an observed medication pass, a certified medication technician (CMT) administered Midodrine without taking the resident’s blood pressure beforehand and stated they did not know what Midodrine was used for, later acknowledging they should have taken the blood pressure first. Another deficiency involved improper administration of ophthalmic medications to a resident with severely impaired cognition, maximal ADL assistance needs, and diagnoses including kidney disease, hypertension, Alzheimer’s disease, aphasia, and seizures. The resident had physician orders for Dorzolamide HCl-Timolol ophthalmic solution and Brimonidine Tartrate ophthalmic solution, both to be instilled in both eyes three times daily for glaucoma/ocular pressure, but the resident’s care plan did not address the need or reason for eye drops. The facility’s eye drop administration policy required specific technique, including forming a pouch in the lower eyelid, avoiding contact of the dropper tip with the eye, compressing the tear duct or keeping the eye closed, wiping excess solution, and waiting 10 minutes between different eye medications. During an observed eye drop administration, the same CMT pried the resident’s eyelids open while the resident resisted and instilled Brimonidine solution in both eyes, then immediately proceeded to administer Dorzolamide-Timolol solution without pausing between the two different medications. This technique did not follow the facility’s eye drop administration policy or the manufacturer’s instructions, which required a waiting period between different ophthalmic solutions. The DON stated an expectation that staff follow the eye drop administration policy, including hand hygiene, glove use, proper eyelid positioning, wiping excess solution, and pausing between different eye solutions.
Failure to Provide Adequate Foot Care and Documentation
Penalty
Summary
The facility failed to ensure proper foot care for a resident, resulting in dry skin and a blister on the resident's left foot. The resident, who was cognitively intact and had diagnoses including vascular dementia, COPD, and CKD, had a physician's order for a head-to-toe skin assessment every Thursday and specific wound care for the left foot. However, there were no orders for lotion or preventive ointments for the resident's dry skin. Skin assessments and shower sheets did not document the resident's dry skin, and the care plan was not updated to address the blister or dry skin. Observations revealed that the resident's left foot had a reddened, raw area with blood and peeled skin, while the right foot had dry, flaky skin. Interviews with staff, including a CNA, LPN, and the DON, indicated awareness of the resident's foot wound and dry skin but a lack of documentation and treatment for the dry skin. The DON and Administrator were not aware of the dry skin issue, and the facility's skin integrity policy was not followed, leading to incomplete and inaccurate skin assessments and shower sheets.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an allegation of injury of unknown origin to the Department of Health of Senior Services (DHSS) within the required two-hour time frame. A resident was found wandering onto another unit, wearing only a brief, with a cord tied around their waist and a bloodied face. Despite the serious nature of the injuries, which included a laceration on the forehead and nose, and bruising on the right side of the face, the incident was not reported to DHSS as an injury of unknown origin. The resident, who was admitted with diagnoses including atrial fibrillation, paranoia, anxiety, restlessness, agitation, history of falling, closed head injury, and dementia with behaviors, was extremely confused and had an unsteady gait. Staff members, including a CMT and a CNA, observed the resident with blood on their face and hands, but due to a language barrier, the resident could not explain what happened. The facility's investigation determined that the injuries most likely occurred due to a fall, but there was no documentation of the incident being reported to DHSS within the required time frame. Interviews with staff revealed that there was confusion about the nature of the incident, with some assuming it was a fall and others noting the seriousness of the injuries. The Administrator concluded the incident was an unwitnessed fall and did not expect staff to report it to DHSS. However, the lack of certainty about the cause of the injuries and the failure to report them as an injury of unknown origin constituted a deficiency in the facility's reporting procedures.
Failure to Maintain Licensed Administrator
Penalty
Summary
The facility failed to have a licensed Administrator responsible for establishing and implementing policies for managing and operating the facility, which had the potential to affect all residents. The issue arose when Administrator A's license expired, and the Director of Business Operations (DBO) had to step in temporarily. The DBO applied for a Temporary Emergency License (TEL) after Administrator A's last day at the facility, but there was a period between the expiration of Administrator A's license and the issuance of the TEL where the facility did not have a licensed Administrator. During this period, the DBO was on site and serving as the Administrator, although he was not licensed. The facility attempted to contract an Administrator, but the arrangement fell through, exacerbating the situation. Interviews with the Interim Administrator and the DBO revealed that there was confusion and a lack of clarity about who was serving as the Administrator during the gap, and the Interim Administrator expected the facility to adhere to regulations requiring a licensed Administrator.
Failure to Conduct NA Registry Checks for New Hires
Penalty
Summary
The facility failed to ensure that newly hired employees were screened for federal indicators of abuse, neglect, or misappropriation of resident property through the Nurse Aide (NA) Registry. This deficiency was identified for three out of ten sampled employees hired since the last survey, despite the facility having hired at least 57 new employees during this period. The facility's Abuse Prevention policy, approved in June 2022, mandates that all employees and volunteers be screened prior to working with residents, including verification of references, certification, license, and criminal background checks. However, the policy was not adhered to, as evidenced by the absence of NA registry checks in the employee files of Employees A, B, and C. Interviews conducted during the survey revealed a lack of awareness and understanding of the requirement to conduct NA registry checks. The Human Resources representative indicated that background checks were completed and stored at the regional office but was uncertain if NA registry checks were necessary for non-nursing staff. The Administrator confirmed that NA registry checks were not performed and was unaware that such checks should have been conducted for non-nursing staff. This oversight in the screening process potentially compromised the safety and well-being of the residents, as the facility did not fully implement its abuse prevention policy.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to provide and offer snacks at bedtime, as snacks were only offered mid-day between lunch and dinner. This deficiency was identified through observations and interviews with staff and residents. The Dietary Manager confirmed that meals were served at specific times, with breakfast at 7:30 A.M., lunch at 12:30 P.M., and dinner at 5:30 P.M. However, residents reported that snacks were not offered after dinner, and one resident mentioned experiencing low blood sugar at night, which was only addressed with pudding. The Activity Director stated that snacks were distributed at 3:00 P.M. during an event called [NAME], but no snacks were routinely offered after dinner unless requested by residents from CNAs. Further investigation revealed that snacks were stored in cabinets by the nurse's station, but only staff were aware of their location. Observations showed that the [NAME] Hall refrigerator contained only health shakes, and the storage cabinets had no snacks. The Dietary Manager mentioned that the dietary department attempted to stock each nursing station every other day, but there was uncertainty about whether snacks were being refilled or if staff and residents were receiving them. The Director of Nursing stated that snacks were supposed to be available after dinner/bedtime, but the current practice did not ensure this availability.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple observations of staff not following established protocols. Staff were observed bringing a treatment cart into an isolation room without cleaning and disinfecting it before moving it to another resident's room. Additionally, during wound care for a resident, staff did not perform hand hygiene between glove changes, failed to disinfect a clean field, and did not sanitize scissors used in the procedure. These actions were contrary to the facility's policies on transmission-based precautions and wound care procedures. Several residents were affected by the facility's failure to implement enhanced barrier precautions (EBP) appropriately. Staff did not wear the required personal protective equipment (PPE) during high-contact activities with residents who had multidrug-resistant organisms or chronic wounds. For instance, a resident with a urinary catheter and another with a PICC line did not receive care with the necessary gown and gloves, as mandated by the facility's EBP policy. The lack of proper signage and communication about isolation and EBP status further contributed to the lapses in infection control. Interviews with facility staff, including the Administrator and Director of Nursing, revealed an expectation for adherence to CDC guidelines and facility policies. However, observations indicated a disconnect between these expectations and actual practices. Staff were not consistently following procedures for cleaning equipment, performing hand hygiene, and using PPE, which are critical components of infection prevention and control in a healthcare setting.
Failure to Notify Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to notify a resident's physician in a timely manner when there was a change in the drainage from a surgical wound and a change in the resident's blood pressure. The resident, who was alert and oriented, had a history of dependence on renal dialysis and a right hip fracture with intramedullary nailing. The resident's care plan included monitoring the surgical site for signs of infection and reporting any changes to the medical doctor. However, the facility did not adhere to its Clinical Protocol for notifying healthcare providers of clinical problems. The resident experienced purulent drainage from the surgical wound, elevated temperature, and low blood pressure over several days. Despite these significant changes, there was a lack of communication between shifts, and the physician was not notified promptly. The night nurse documented the resident's condition but failed to ensure that the day nurse contacted the physician. The resident's blood pressure readings were consistently low, and the surgical site showed signs of infection, yet these issues were not communicated effectively to the attending physician or the orthopedic surgeon. Interviews with nursing staff revealed inconsistencies in reporting and documentation practices. Some nurses did not receive complete reports from the previous shift, and there was confusion about whether the physician had been notified. The Director of Nursing and Administrator expected staff to notify the physician immediately in case of a change in condition, but this did not occur. The failure to notify the physician in a timely manner resulted in a delay in addressing the resident's medical needs, as evidenced by the eventual decision to send the resident to the emergency room.
Medication Mismanagement and Delayed Hospital Transfer
Penalty
Summary
The facility failed to meet professional service standards by not clarifying medication orders and documenting the same medication in multiple forms, leading to duplicated doses for a resident diagnosed with Alzheimer's disease, unspecified dementia, and GERD. The resident had conflicting orders for pantoprazole, with both tablet and suspension forms being documented as administered. Interviews with LPNs revealed uncertainty about the last administration date due to expired medication and duplicate orders in the electronic system, which had been down for over a month. The Medical Director confirmed the correct order and emphasized the need for staff to verify duplicate orders before administration. Additionally, the facility did not follow physician orders for another resident who required timely hospital transfer due to a dehisced surgical incision with signs of infection. Despite the physician's orders to send the resident to the hospital, the transfer was delayed. Interviews with nursing staff revealed communication lapses and task delegation issues, resulting in the resident remaining at the facility longer than necessary. The DON and Administrator expressed expectations for timely assessment and transfer following physician orders, which were not met in this case. The report highlights significant deficiencies in medication management and adherence to physician orders, impacting resident care. The facility's failure to address duplicate medication orders and ensure timely hospital transfers for residents with urgent medical needs demonstrates a lack of compliance with professional standards and facility policies.
Failure to Implement Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to adhere to its policy regarding the administration of PRN psychotropic medications, specifically for a resident with moderately impaired cognition and behaviors such as rejection of care and wandering. The resident, who had diagnoses including stroke, dementia, and malnutrition, was prescribed Lorazepam, an antianxiety medication, on an as-needed basis without a specified stop date. The facility's policy mandates that PRN psychotropic medications should have a stop date of 14 days or less unless a practitioner documents the rationale for an extended order. However, the order for Lorazepam did not include an end date, and the medication was administered multiple times over a three-month period without reevaluation or reordering. Interviews with the Director of Nursing and the administrator confirmed that the facility's standard practice is to have a 14-day stop date for PRN antianxiety medications, with a requirement for reevaluation and reorder. Despite this policy, the resident's PRN Lorazepam order lacked a stop date, indicating a failure in the facility's medication management practices. This oversight was identified during a survey, highlighting a deficiency in the facility's compliance with its own policies and federal regulations regarding the use of psychotropic medications.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, as observed during a survey. Three out of five medication carts and both medication rooms were inspected, revealing issues in the medication room refrigerators. An expired bottle of Pantoprazole suspension, used for treating heartburn, was found in the medication storage refrigerator for a resident. Additionally, an opened vial of tuberculin purified protein derivative (PPD) solution was not dated, which is necessary to track its usability period. The facility's policies on medication storage and disposal were not adhered to, as evidenced by the expired medications not being discarded and the lack of proper dating on opened medications. The facility's Storage of Medications policy requires nursing associates to maintain medication areas in a clean, safe, and sanitary manner, and to dispose of discontinued or outdated drugs. However, the staff failed to follow these guidelines, as demonstrated by the expired Pantoprazole and undated PPD vial. Furthermore, the facility did not maintain accurate temperature logs for the medication refrigerators. The temperature logs for May and June showed several missing entries and instances where temperatures were out of the acceptable range. Interviews with staff revealed that night shift nurses were responsible for logging refrigerator temperatures, but this was not consistently done. The Administrator was unaware of the missing logs and expected staff to discard expired medications, date opened medications, and log refrigerator temperatures daily.
Survey Results Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to make the results of the most recent survey and complaint investigations readily accessible to residents, family members, legal representatives, and visitors. Observations on multiple dates revealed that no survey results were displayed at the entrance, lobby, or receptionist desk, and there were no signs indicating their location. During a group interview, residents expressed their inability to locate the survey binder. When residents requested the binder from the receptionist, it could not be found, and the receptionist was unaware of its location, suggesting it might be in a storage room due to lobby construction. The Assistant Director of Nursing and the Administrator both acknowledged that the binder was typically kept in the front lobby but were unsure of its current whereabouts.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lemay Nursing | 1.6 mi | ★★★★★ | 0 | 0 |
| Bluebird Wellness And Rehabilitation | 1.7 mi | ★★★★★ | 1 | 0 |
| Nazareth Living Center | 3.3 mi | ★★★★★ | 4 | 0 |
| Mary, Queen And Mother Center | 3.3 mi | ★★★★★ | 3 | 0 |
| St Louis Altenheim | 4 mi | — | 20 | 0 |
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